Quality of Life in Low-Grade Non-Hodgkin’s Lymphoma

Quality of Life in Low-Grade Non-Hodgkin’s Lymphoma

Cancer treatment often has debilitating effects on the patients who
receive it. Chemotherapy regimens can produce toxicities, such as
gastrointestinal disturbances, hematologic deficiencies, fatigue, and
neurotoxicity. Patients typically undergo these chemotherapy regimens
to increase their disease-free survival time. Given that these
therapies can negatively affect a patients quality of life
(QOL), treatments need to provide clear curative potential and/or
survival benefits to offset detrimental effects on QOL.

Webster and Cella describe a case in which the benefits exchanged for
the risks of therapy are unclear. As they describe, the therapies for
low-grade non-Hodgkins lymphoma (NHL) do not provide a clear
benefit in terms of cure or overall survival. The authors therefore
conclude that extensive treatment may not be warranted because of the
great impact of these therapies on QOL.

When Are the QOL Consequences of Treatment Important?
We concur with Webster and Cella that QOL should be considered when
making treatment decisions. There are several clear-cut circumstances
in which the effects of treatment on QOL become an important
decision-making tool. For example, the QOL consequences of treatment
are particularly significant when the treatments being considered
yield similar advantages in survival but have different
toxicities.[1] This appears to be the case for the treatment options
for low-grade NHL, as described by Webster and Cella.

Multiple treatment options exist, including observation only, that
have little effect on overall survival but a highly variable impact
on QOL. However, these treatments do appear to differ in how they
affect other disease related variables, such as the speed of
treatment response and time to recurrence.

Although overall survival is usually considered to be the bottom
line in evaluating therapies, treatment efficacy in terms of
time to recurrence should not be underemphasized. For a patient
facing the long-term management of a chronic, incurable disease, the
amount of time that he or she remains free of disease or with stable
disease may be important. This is particularly true if the disease
itself produces debilitating symptoms. However, for patients whose
disease does not manifest serious symptoms, as is the case for many
individuals with low-grade NHL, the advantage provided by a longer
time to progression may be primarily psychological.

According to Webster and Cella, for patients with low-grade NHL,
progression is slow, symptoms are few, and therapies offer little
survival advantage. Thus, the complexity of QOL considerations must
be carefully evaluated.

To date, research on the QOL of patients with low-grade NHL is
limited. Even the data presented by Webster and Cella are not
specific to low-grade NHL. Thus, more research is needed before
strong conclusions can be made about treatment strategies for
low-grade NHL that optimize both medical benefit and QOL.

Assessing Patients Preferences
Although QOL may be compromised as the result of treatment, patients
may be willing to endure these difficulties if therapy offers a
longer symptom-free interval, or even the remote chance of cure or
increased survival. The ambiguity surrounding the appropriateness of
treatment for low-grade NHL indicates the need for information on
patients preferences for treatment outcomes, taking into
account both changes in QOL and life expectancy.

One group of methods for quantifying patients desires regarding
treatment decisions is the assessment of utilities, or patient
preferences. Utilities are used by decision scientists in evaluating
treatment options based on a patients preference for a
particular health state.[2] A patient-generated utility is a measure
of the patients perception of the degree of impact of a
particular outcome, such as neurologic problems or infertility.
Utility is often assessed using such methods as the time trade-off,
which seeks to determine the number of years of healthy life that a
participant is willing to trade off for remaining free of
an adverse health condition.

Utilities assess the value of a health state or outcome in reference
to a universal standard, such as time, money, or risk of death.[3]
This assessment technique is particularly useful when the same
adverse event may be perceived differently by different people. These
preferences can then be incorporated into formal decision-analytic
models to determine the optimal treatment choice.

Need for Psychosocial Interventions
Even when treatment decisions take patient preferences into account,
the management of the disease is likely to have consequences for
patients QOL. Patients who receive aggressive treatment must
cope with the difficult side effects of chemotherapy. Patients who
opt for the strategy of watchful waiting may experience
stress and anxiety related to not treating the disease.

The impact of low-grade NHL on patients QOL points to the need
for psychosocial interventions to aid psychological adjustment and
improve QOL. These programs may be implemented regardless of the
treatment strategy chosen.

Several recent reviews have documented the effectiveness of
psychosocial interventions in helping cancer patients adjust to their
diagnosis and treatment.[4-7] Cognitive and behavioral interventions,
such as guided imagery and progressive muscle relaxation, have been
found to effectively reduce chemotherapy-induced symptoms and
conditioned side effects, such as nausea and vomiting (see Fawzy et
al[5]). In addition, cognitive-behavioral and more general support
group-based interventions can be effective in improving psychological
well-being and increasing overall survival time.[8,9] Group or
individual psychosocial intervention programs can be useful at
different stages of disease and treatment, and they need to be made
available to all patients.

Although no studies have tested the use of such interventions to help
patients cope with the stress of not treating a disease, this could
be a fruitful area of research for both low-grade NHL and other
cancer sites characterized by slow progression (eg, prostate cancer).

Treatment Risks vs Benefits
Although inclusion of QOL outcomes should be considered when making
treatment decisions for diseases such as low-grade NHL, patients'
preferences for the trade-off between treatment risks and benefits
should also be considered. However, because current methods for
assessing utilities are complex and may be impractical in some
settings,[3] further methodologic research is needed to improve
assessment techniques.

Patients need to be well informed of the consequences of a particular
treatment decision, but they also need to be aware of the beneficial
effects treatments can have on the disease process. Active
involvement in group, individual, and/or personalized psychosocial
intervention programs can be a useful adjunct to traditional medical treatment.

Unfortunately, for many patients, these types of programs are not
available or affordable. Future research needs to definitively
determine the cost-efficacy of these intervention programs so that
they can be made available to all patients battling life-threatening illnesses.